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<!--Begin CTCT Sign-Up Form-->
<!-- EFD 1.0.0 [Mon Aug 28 11:09:22 EDT 2017] -->
<div class="ctct-embed-signup">
<div>
<span id="success_message" style="display:none;">
<div style="text-align:center;">
<h3 class="article--title">
Thank you for taking the next step in healing your arthritis. You should receive your video in your email shortly.
</h3>
</div>
</span>
<form data-id="embedded_signup:form" class="ctct-custom-form Form" name="embedded_signup" method="POST" action="https://visitor2.constantcontact.com/api/signup">
<p></p>
<!-- The following code must be included to ensure your sign-up form works properly. -->
<input data-id="ca:input" type="hidden" name="ca" value="fd342522-1003-4f26-ba37-ae62bf64ef16">
<input data-id="list:input" type="hidden" name="list" value="2091333883">
<input data-id="source:input" type="hidden" name="source" value="EFD">
<input data-id="required:input" type="hidden" name="required" value="list,email,first_name">
<input data-id="url:input" type="hidden" name="url" value="">
<div class="clear mc-field-group">
<p data-id="Email Address:p" >
<label data-id="Email Address:label" data-name="email" class="ctct-form-required"></label> <input data-id="Email Address:input" type="text" placeholder="Email Address" name="email" value="" maxlength="80">
</p>
</div>
<div class="clear mc-field-group">
<p data-id="First Name:p" >
<label data-id="First Name:label" data-name="first_name" class="ctct-form-required"></label> <input data-id="First Name:input" type="text" name="first_name" placeholder="First Name" value="" maxlength="50">
</p>
</div>
<div class="clear mc-field-group">
<button type="submit" class="Button js-btn button ctct-button Button--block Button-secondary" data-enabled="enabled">Send Me The Free Video!</button>
</div>
<!--
<p class="ctct-form-footer">By submitting this form, you are granting: Blum Center for Health, 34 Rye Ridge Plaza, Rye Brook, New York, 10573, United States, http://www.blumcenterforhealth.compermission to email you. You may unsubscribe via the link found at the bottom of every email. (See our <a href="http://www.constantcontact.com/legal/privacy-statement" target="_blank">Email Privacy Policy</a> for details.) Emails are serviced by Constant Contact.</p>
-->
</form>
</div>
</div>
<script type='text/javascript'>
var localizedErrMap = {};
localizedErrMap['required'] = 'This field is required.';
localizedErrMap['ca'] = 'An unexpected error occurred while attempting to send email.';
localizedErrMap['email'] = 'Please enter your email address in name@email.com format.';
localizedErrMap['birthday'] = 'Please enter birthday in MM/DD format.';
localizedErrMap['anniversary'] = 'Please enter anniversary in MM/DD/YYYY format.';
localizedErrMap['custom_date'] = 'Please enter this date in MM/DD/YYYY format.';
localizedErrMap['list'] = 'Please select at least one email list.';
localizedErrMap['generic'] = 'This field is invalid.';
localizedErrMap['shared'] = 'Sorry, we could not complete your sign-up. Please contact us to resolve this.';
localizedErrMap['state_mismatch'] = 'Mismatched State/Province and Country.';
localizedErrMap['state_province'] = 'Select a state/province';
localizedErrMap['selectcountry'] = 'Select a country';
var postURL = 'https://visitor2.constantcontact.com/api/signup';
</script>
<script type='text/javascript' src='https://static.ctctcdn.com/h/contacts-embedded-signup-assets/1.0.2/js/signup-form.js'></script>
<!--End CTCT Sign-Up Form-->
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